Author: larissa@ravelbrands.com

Last updated: June 2026

A running, periodically updated note on developments in health equity, organizational strategy, and healthcare leadership that I’m tracking right now  and why they matter for how this work actually gets built inside organizations.

1. The infrastructure is being quietly dismantled before the language is

Federal agencies have spent the past year working through directives to remove equity-related language and roles from public-facing operations, and the campaign has extended into asking employees to report colleagues still doing this work under different names. What I’m watching isn’t the language fight — it’s the underlying infrastructure fight. Reporting systems, designated roles, and review processes are being eliminated alongside the language, which means even organizations that want to keep substance while dropping vocabulary may find the operational scaffolding gone too. This is the exact gap I wrote about in my own research: roles can disappear quietly long before anyone announces a strategic retreat.

2. Health equity data infrastructure is the story underneath the story

Several outlets covering health policy this year have flagged a quieter risk than budget cuts: shifts in how federal agencies collect and report demographic health data. If the categories used to measure disparities get suppressed or reclassified, organizations lose the ability to demonstrate a gap even exists — which means the ROI conversation I keep getting asked about becomes nearly impossible to win with data, regardless of how real the underlying problem is. Worth watching closely for any organization whose equity strategy depends on externally sourced demographic benchmarks rather than its own internal data.

3. Layoffs are landing hardest on the layer where this work lives

The 2026 healthcare layoff trackers tell a consistent story: corporate, nonclinical, and administrative roles are absorbing a disproportionate share of workforce reductions as systems respond to Medicaid funding pressure and tightening margins. That’s exactly the layer where most health equity and DEI functions sit organizationally. None of the layoff announcements I’ve reviewed name equity work specifically as the rationale — the stated reasons are almost always financial — but the practical effect on a function with shallow budget and staffing depth to begin with is the same regardless of the stated cause.

4. The industry’s own consultants are recommending embedding, not standalone functions

Several 2026 industry trend reports — including from firms advising pharma and health systems directly — are now explicitly recommending that equity-centered work move out of standalone offices and into core operating functions: R&D, finance, patient engagement, analytics, IT. I read this less as retreat and more as a forced correction toward what I’ve argued all along — that a strategy bolted onto the org chart as a freestanding office, without budget parity or real authority, was always going to be fragile. The current pressure may be accelerating a shift that should have happened on its own terms years ago.

5. A split is forming between public-sector retreat and private-sector reframing

Public agencies are moving toward elimination. Large private health systems and payers are mostly moving toward relabeling — folding the work into value-based care, ESG reporting, or social determinants of health initiatives rather than eliminating it outright. Both paths reduce the visibility of equity-specific titles. Only one of them, in my read of the data so far, is likely to preserve the actual operating budget and infrastructure underneath the title. The organizations worth watching closely over the next year are the ones that can tell you which path they’re actually on — most can’t yet.

6. Managed care is quietly becoming the default vehicle for equity-relevant work and it’s under its own financial strain.

Special needs plans, particularly those serving people dually eligible for Medicare and Medicaid, are one of the fastest-growing segments in Medicare Advantage this year, and they’re increasingly where population health and equity-adjacent work actually lives operationally — case management, social needs screening, care coordination for chronically ill and low-income members. At the same time, Medicaid work requirements are set to take effect in 2027, and managed care plans broadly are navigating real margin pressure, which has already led several insurers to scale back supplemental benefits. I’m watching this closely because it’s the same pattern as the title-without-infrastructure problem, just one layer down: the population most likely to benefit from equity-centered care is increasingly served through a financing mechanism that’s simultaneously being asked to tighten its belt. Worth tracking whether plans protect these supports as core to the model or treat them as the first thing to trim when margins get tight.

I’ll keep adding to this as the year moves. If you’re navigating any of this inside your own organization, I’d be glad to talk through it.

Leaders running equity, inclusion, or mission-driven strategic initiatives are facing a problem that didn’t exist in quite this form three years ago: they’re being asked to prove the financial case for their work faster and more rigorously than ever, at the exact moment the language and framing they used to make that case has become politically risky to use out loud.

This is a two-front problem, and most of the advice circulating right now only addresses one front at a time.

The Two-Front Problem

The first front is financial. Boards and finance leaders are asking sharper questions about return on investment for this kind of work than they did a few years ago, when public commitment alone was often enough. That’s not unreasonable — every function in an organization is expected to justify its resourcing, and this work shouldn’t be exempt from that discipline.

The second front is political. The same language that used to anchor the story — naming disparities directly, centering identity, using certain terms of art — is now triggering a different kind of scrutiny, separate from whether the work is effective. Leaders are getting squeezed from both directions: prove the ROI, and do it without the vocabulary you used to build the case in the first place.

The instinct under that pressure is to go quiet on both fronts — soften the story and hope the ROI conversation doesn’t come up. That’s the wrong move. It usually just delays a harder conversation later, on worse terms.

Why the Old Storytelling Playbook Is Stalling

Most storytelling for this kind of work was originally built to do one thing: build moral and cultural urgency. It centered lived experience, named the gap, and asked the audience to care. That approach worked when the organizational mandate was “show us you’re serious.” It works much less well when the mandate has shifted to “show us this is worth the spend, and do it in language leadership is comfortable repeating publicly.”

The problem isn’t that the work stopped mattering. It’s that the story and the financial case were built as two separate documents — a narrative for hearts, a deck for budgets — and in this moment, organizations need both to live in the same sentence.

Reframe the ROI Question Before You Try to Answer It

Before producing a new story or a new business case, it’s worth checking whether the ROI question being asked is actually answerable in the terms you’ve been using. Most initiatives like this already sit on outcome data the rest of the organization already values — retention, engagement scores, customer or patient satisfaction, complaint volume, risk and compliance exposure. The fastest path forward usually isn’t generating new proof; it’s translating proof you already have into a financial vocabulary that doesn’t require anyone in the room to take a position on language they’re currently avoiding.

What to Do This Week

1. Pull your last three pieces of storytelling and your last financial justification side by side. If they don’t share a single data point, that’s the gap to close first — not the narrative, the connective tissue between narrative and number.
2. Identify three hard metrics already inside your organization’s existing dashboards — not new ones you’d have to build — that this work plausibly moves: retention, engagement, complaint volume, time-to-resolution, whatever your organization already tracks. Anchor the next version of the story to those, explicitly.
3. Rewrite your core narrative once for a skeptical stakeholder, not your most supportive one. If it survives being read aloud in a room that’s politically cautious, it’s durable. If it only works with an already-convinced audience, it isn’t ready yet.
4. Build a small portfolio of proof points instead of one flagship story. A single narrative is fragile — easy to dismiss as anecdote, easy to politicize. Three or four smaller, metric-anchored examples are harder to wave away and easier to repeat without controversy.
5. Decide, deliberately, what language is load-bearing and what isn’t. Some terminology matters because it’s accurate and necessary. Other terminology is a habit from an earlier moment. Knowing the difference lets you hold your ground on the first and let go of the second without feeling like you’re compromising the work.

The work doesn’t need a louder story right now. It needs a story and a financial case that were built to survive being read by someone who isn’t already on your side, because increasingly, that’s exactly who’s in the room.

If you want to know whether a strategy is actually working, who do you ask?

Most leaders ask the people closest to the work. It feels like the right instinct — get out of the C-suite, talk to the managers actually running programs day to day. My own research, and my own years sitting in that exact seat, point to something every executive should sit with before treating that feedback as the full picture: the answer you get depends entirely on where the person you’re asking sits in the organization, and that gap is wider, and more consequential, than most leadership teams realize.

The View From the Middle

I spent years as a director at a Fortune 10 health care company, in the layer of the organization that sits between strategy and execution — close enough to the work to feel every resourcing gap, far removed enough from the C-suite that I rarely had visibility into why those gaps existed. What reached me were the announcements: a new strategic pillar, a new executive hire, a renewed sense that the organization was finally paying attention to an issue I cared about. What didn’t reach me, most of the time, were the budget conversations, the political resistance, or the quiet deprioritization happening one or two floors up. I had every reason to be encouraged. I just didn’t have the full picture.

That experience is what sent me looking for the pattern formally.

What the Research Confirmed

I studied two groups inside the same kinds of organizations: senior executives charged with building health equity strategy from scratch, and the middle managers responsible for carrying that strategy out. I expected their views of organizational progress to roughly align. They didn’t — not even close.

The executives, almost without exception, described frustration: insufficient budget, unclear mandates, leadership that wasn’t ready to engage with hard truths. The middle managers, working inside the very same systems, were largely optimistic. Many pointed to their leadership with real confidence — “we have a new Chief Diversity Officer who’s changing how we do business,” one told me — genuinely encouraged by signs of progress that, from one level up, looked more like the opening move in a fight than evidence of one being won.

Two Worlds, One Building

Neither group was wrong. They were looking at different parts of the same building. Middle managers typically don’t sit in the rooms where budgets get fought over or priorities get quietly shelved. What reaches them is the announcement, the new title, the renewed sense that someone is paying attention — genuinely meaningful information, just incomplete. Executives see the resourcing fights and the resistance up close, which gives them a more critical, and usually more accurate, read on how much has actually changed.

This is a hierarchy problem, not a people problem. It’s also not unique to health equity work — it’s a structural feature of how information moves, or fails to move, through any large organization.

Why This Should Concern Leadership

If leadership only checks in with the layer closest to execution, they will consistently get a rosier picture than the data warrants — not because anyone is misrepresenting reality, but because nobody in that conversation has visibility into the whole system. Optimism from the middle of your company is not the same as proof that your strategy is working, and treating it as confirmation is one of the easier ways for a leadership team to mistake activity for progress.

There’s a cost on the other side of this gap, too. The managers I studied, and the one I once was, had on-the-ground instincts that would have meaningfully sharpened the strategy — if anyone had asked before the rollout instead of after. Organizations that only use the middle layer to confirm what they already believe are leaving real strategic input on the table.

What Leaders Should Do Differently

Closing this gap doesn’t require another listening session. It requires building real lines of sight in both directions:

1. Don’t mistake departmental optimism for system-level proof. Pair frontline sentiment with a direct, honest account from the people closest to the resourcing decisions — they’re rarely describing the same reality.
2. Pull middle managers into strategy formation, not just rollout. The people executing the work often have the clearest read on what will and won’t function in practice, but only if they’re consulted before the plan is finalized.
3. Give the middle layer enough context to see the whole system, not just their piece of it. Information flowing only downward as announcements, with none of the surrounding reality, produces confidence that isn’t actually earned.

That’s the actual work: an organization built to hear itself clearly, top to bottom — not one that mistakes the most reassuring answer for the truest one.

Over the past several years, hundreds of health systems created a new kind of executive role: Chief Health Equity Officer, Chief Diversity Officer, or some hybrid of the two. The titles carried real weight. The mandates were ambitious — close racial health gaps, rebuild trust with marginalized communities, transform how the organization operates. Many of these roles also failed within two or three years.

The instinct is to ask what went wrong with the leader. My research suggests that’s the wrong question. In my interviews with executives hired into these roles across the country, a different pattern emerged: the common factor wasn’t individual performance. It was whether the organization had built the conditions for the strategy to succeed in the first place.

The Title Arrives Faster Than the Infrastructure

Nearly every leader I interviewed described starting their role the same way: no budget, no staff, no precedent, and no internal benchmark for what success should look like. One put it simply: “I started from zero.” These weren’t underqualified hires — many held doctorates, decades of operational experience, and exactly the credentials you’d expect for a C-suite appointment. The shortfall wasn’t in who was hired. It was in what the organization built around them.

This gap has a predictable origin. The decision to create these roles often moved at the speed of public pressure. In many cases, in direct response to 2020’s social unrest. The infrastructure to support them, budget allocation, reporting lines, staff, authority, moved at the speed of internal bureaucracy, which is to say, far more slowly, if it moved at all. The result is a title without the operating mechanics of the role it’s named for. A “Chief” position with no budget isn’t a peer to the CFO or CHRO. It’s a symbol with a salary attached.

Censorship Compounds the Resource Gap

A second pattern made the first one worse: many of these leaders described being implicitly or explicitly discouraged from naming the problem they were hired to solve. Several recounted avoiding the word “racism” in strategy documents intended for external audiences, not because the data didn’t support it, but because leadership wasn’t ready to see it in writing. One executive described the calculation required to raise structural racism with her board: rehearsing tone, moderating delivery, managing how she’d be perceived before she could even get to the substance.

This is a second, quieter form of under-resourcing. It’s not just that these leaders lack budget, many also lack the organizational permission to describe the problem accurately. Strategy built on a euphemism is strategy that can’t be fully executed.

Why This Should Concern Leadership

The cost of this pattern isn’t confined to the individual in the role. Average tenure in these positions runs under two to three years, and every cycle of turnover carries a compounding cost: recruitment and onboarding spend, lost institutional momentum, and, perhaps most damaging, a credibility cost with employees, patients, and communities who watched a public commitment quietly stall. A pattern of short-tenured equity leadership becomes its own signal, whether or not it’s intended as one.

This reframes the conversation that typically follows a departure. The default explanation is usually “the wrong fit.” The data points elsewhere: a structural failure to build the operating conditions — budget, authority, reporting access, and a leadership team willing to hear the truth — that any other strategic executive role would have by default.

What This Means for Leaders Building These Roles

The political climate around this work has shifted considerably since most of these roles were created in 2020 and 2021. That shift makes the underlying question more urgent, not less: organizations that built these positions on public pressure rather than operating infrastructure are now finding that pressure was the only thing holding the role up. Before creating a senior DEI or health equity role, or evaluating why a previous one quietly disappeared, five questions are worth asking with real honesty:

1. Does the role have a real budget and staff — comparable to other C-suite functions — or is it a senior title operating with junior-level resources?
2. Does the role have a direct line to the CEO and board, with a seat in the rooms where resourcing decisions actually get made, or is it routed through a layer that limits its visibility and authority?
3. Is the business case for this work documented in terms the organization already uses to justify any other strategic investment — retention, patient outcomes, market share, risk exposure — or does it rely entirely on cultural and political goodwill that can evaporate with the news cycle?
4. Has the organization stress-tested this role against a hostile environment — reduced public appetite, legal and regulatory scrutiny, leadership turnover — or was it designed for the conditions of one particular moment?
5. Is leadership genuinely prepared to hear an honest diagnosis, including naming structural dynamics directly where the data supports it, or only a version of the problem that’s been pre-softened for comfort?

If the honest answer to more than one of these is no, the organization hasn’t built the conditions for the strategy it says it wants. It’s built a title that was only ever as durable as the pressure that created it. The leaders best positioned to weather what’s happening now are the ones whose roles were embedded in operating infrastructure and business logic from day one, not the ones who were counting on the moment to last.